Ilizarov Frame

Ilizarov Frame

Sonya Clarke

The proposed answer plans offer ‘lists of potential responses’ with limited rationale. It is therefore recommended for the individual student/healthcare professional to explore the issues through further reading.


Question 1. What is an Ilizarov frame/Ilizarov technique?

Ilizarov frame/fixation is used for fracture fixation and stabilisation, limb reconstruction, deformity correction, and limb lengthening, using wires instead of pins and a circular frame instead of bars (Santy et al. 2009).

Ilizarov technique: a bone-fixation technique using an external fixator for lengthening limbs, correcting pseudarthroses and other deformities, and assisting the healing of otherwise hopeless traumatic or pathological fractures and infections, such as chronic osteomyelitis. The method was devised by the Russian orthopaedic surgeon Gavriil Abramovich Ilizarov (1921–1992) (G.A. Ilizarov – Ilizarov Centre).

Question 2. Reflecting upon the nursing process and a model of care how would the children’s nurse prepare this young person and their family for application of an Ilizarov frame?

Activity of living: maintaining a safe environment.

Assess: determine the young person’s and parents’ level of knowledge in relation to all aspects of hospitalisation care.

Plan: the children’s nurse must ensure Patrick and his parents are given appropriate preoperative preparation at ward level, which will involve physical and psychological care, the induction of a general anaesthetic (GA), pain management, the actual surgical procedure, and what to expect post-surgery regarding application of the Ilizarov frame (as shown in Table 26.2). All planned care should adopt an appropriate model of nursing, for example Casey (1988) and Roper et al. (1990). Please note, even though Roper et al. (1990) addresses 12 activities of daily living (ADL) (refer to Chapter 1) this chapter will only address the problems in preoperative and post-operative care in relation to the ADL – maintaining a safe environment.

Table 26.2 Phases of treatment.

Latency period: initial post-operative period
Distraction (approx. 1/3 of time in frame)
Starts about 5–7 days post-operatively
mm day divided into four increments or 0.25 cm every six hours
Consolidation (approx. 2/3 of time in frame)
Removal of frame (6–12 months approx.)

Implement/preoperative interventions:

  • Patrick should be settled into an allocated bed space appropriate for his age, be comfortable with the ward surroundings, and introduced to the nurse assigned to his care.
  • Globally the needs of children and young people differ to those of adults and an increasing expectation is that children and young people should participate in health care decisions that affect them (Clarke 2021). Therefore, the care should have Patrick at the centre and be inclusive of the family, for example consideration given to their views, open visiting, and access to tea-making and overnight facilities for a parent if required. Explain what an Ilizarov frame is, show pictures, models and if possible, introduce Patrick and parents to another child with a frame in situ.

  • Facilitate Patrick and his parents to raise any concerns they have regarding application of the frame, complications, returning to school, social activity, and the effects of altered body image for a 14-year-old boy.
  • Complete and record base line vital signs on a paediatric early warning score (PEWS) chart, for example – temperature, pulse, pain score, respirations, SAO2, and blood pressure (BP).
  • Complete a ward urinalysis, if nothing abnormal detected (NAD) record and proceed, otherwise report and send mid-stream specimen of urine (MSSU) to laboratory for organism and sensitivity (O&S).
  • Record weight and height accurately.
  • Apply patient identification armband(s).
  • Complete baseline venapuncture (may be undertaken by nurse or doctor) and send to laboratory as ordered by anaesthetist, full blood picture (FBP), and urea and electrolytes (U&E), plus ‘group and hold’ (blood for transfusion usually not ordered as operation carried out using tourniquet with minimal blood loss).
  • Teach an appropriate pain assessment tool, a scale of 0–10 would be appropriate for a 14-year-old young person, where 0 is ‘no pain’ and 10 is the ‘most imaginable pain’ (Clarke 2003a).
  • Discuss potential pain management options:

    • – Patient controlled analgesia (PCA)
    • – Continuous epidural infusion (Clarke 2003b; Wheetman 2006)
    • – Intravenous paracetamol (Clarke & Richardson 2007) and step-down medication.

  • Record full medical history, known allergies, establish if smoker/non-smoker, any family problems with a GA, etc.
  • Facilitate informed consent (medical responsibility) through verbal, written, and visual display of an Ilizarov frame.
  • Multidisciplinary approach and introduction to team: anaesthetist, consultant, named nurse, physiotherapist, occupational therapist (OT), and specialist Ilizarov nurse.
  • Information on maintaining an Ilizarov frame, i.e. pin site care.
  • Risk assessment using a dedicated tool, for example Waterlow (1998) score, and placed on appropriate pressure relieving device (bed and mattress).
  • Plan discharge date.
  • Preoperative fasting times as per anaesthetist’s instructions (normally two hours for fluids and six hours for solids), patient shower, clean bed, gown in situ, and premedication administration if prescribed.
  • Check out system; confirm patient details are correct, weight, allergies noted, notes, blood results and X-rays available, confirm signed consent form, and pre-medication administered if ordered. Gaining Patrick’s verbal assent to the procedure, reinforces them as a service user and rights holder (UNCRC 1989). Also record if fasting times are adhered to and offer parents to accompany Patrick to theatre.
  • Prepare Patrick’s bed space to ensure a safe environment following his return from surgery – collect appropriate documentation, check oxygen and suction equipment is working, and gather any necessary monitoring or infusion devices.
  • Evaluate all nursing interventions and complete all appropriate documentation as per hospital policy.

Question 3. Discuss the nursing care of Patrick in relation to the immediate post-operative period (first 24 hours), having returned to the ward

Activity of living: maintaining a safe environment.

Assess and plan post-operative interventions:

  • Person-centred approach inclusive of parents, i.e. consider the parents when collecting Patrick from recovery and returning to the prepared bed space.

Implement post-operative interventions:

  • Attach Patrick to appropriate monitoring and infusion equipment as per hospital policy.
  • Read medical and nursing notes, adhering to anaesthetist and surgeon instructions.
  • Ensure Patrick is comfortable, using appropriate tool, i.e. assess pain score (0–10), reposition Patrick, review risk assessment, for example Waterlow (1998).
  • Observations to be completed and recorded on dedicated post-operative chart with appropriate action as per hospital protocol:

    • – TPR, SAO2 (oxygen saturations), and BP
    • – Neurovascular observations of the operated lower limb are imperative, inclusive of pain intensity as he is at risk of developing acute compartment syndrome (RCN 2014)

  • Check actual Ilizarov frame (as above), pin sites for ooze, bleeding, and signs of infection.
  • Hospital protocol must be adhered to regarding care of cannula, i.e. patency and management of intravenous (IV) fluids
  • Record all input and output on a fluid balance chart.
  • Administer analgesia as ordered by anaesthetist. Patrick would most likely receive either a morphine based PCA, or an epidural infusion with a local anaesthetic. Both would be in conjunction with regular IV paracetamol. Nurse to observe for potential side effects of opioids. Analgesia can be used in conjunction with non-pharmacological methods, for example music.
  • Monitor IV fluids and cannula site (as per hospital protocol). Patrick may also tolerate sips of water later in the day as directed by the anaesthetist . Also monitor output on fluid balance chart, reporting any concern to anaesthetist. Patrick may also have an indwelling urinary catheter – this often accompanies an epidural infusion (Wheetman 2006) which associated with orthopaedic surgery.
  • Patrick to be reviewed by pain management team and physiotherapist.
  • Occupational therapist to review Patrick to make foot splint which aims to prevent neurovascular complication, i.e. dropped foot.
  • Consider Patrick’s altered body image and privacy needs of a young person.
  • Patrick to be reviewed by Ilizarov team: orthopaedic consultant, anaesthetist, physiotherapist and specialist nurse.
  • Administer IV prophylactic antibiotics as per hospital protocol.
  • Complete check X-ray as per consultant’s instruction.

Evaluate all nursing interventions and documents.

Question 4. In an attempt to prevent pin site infection, how will Patrick be educated and supported to undertake pin site care/management

A review by Georgiades in 2018:36 states, ‘the goal of pin site care is to reduce, or where possible, prevent pin site infection’. The author also reports on the care of external fixator pin sites to remain debated and researched among scholars, this has highlighted a number of variances and issues in pin site care. There is an absence of high-quality data and research to support any one particular type of dressing in reducing pin site infection, including the use of pin site crusts (Lethaby et al. 2013; Timms & Pugh 2012). The use of multiple pins has increased the risk of complications such as intractable pain, tethering and tenting of the surrounding skin, muscle spasm, swelling and soft tissue tension, and infection at the pin site, which is the main concern and can result in loosening of the pin, loss of fixation and osteomyelitis (Patterson 2005). In the UK the expert British nursing consensus group on pin site care (Lee-Smith et al. 2001) differentiate clearly between the term’s ‘reaction’, ‘colonisation’, and ‘infection’ when discussing pin site care. Pin site care which is identified by Santy (2000) as requiring specialised nursing care is a psychomotor skill initially undertaken by the nurse and then executed by either the child or parent following appropriate education and a period of supervised practice. The most up-to-date Cochrane review on site care for preventing infections associated with external bone fixators and pins remains by Lethaby et al. in 2013 is presented in Table 26.3.

Table 26.3 Cochrane review by Lethaby et al. (2013) – current best level of evidence.


  1. A total of eleven trials (572 participants) were eligible for inclusion in the review but not all participants contributed data to each comparison.

    Three trials compared a cleansing regimen (saline, alcohol, hydrogen peroxide, or antibacterial soap) with no cleansing (application of a dry dressing), three trials compared alternative sterile cleansing solutions (saline, alcohol, peroxide, povidone iodine), three trials compared methods of cleansing (one trial compared identical pin site care performed daily or weekly and the two others compared sterile with non-sterile techniques), one trial compared daily pin site care with no care and six trials compared different dressings (using different solutions/ointments and dry and impregnated gauze or sponges).

    One small, blinded study of 38 patients found that the risk of pin site infection was significantly reduced with polyhexamethylene biguanide (PHMB) gauze when compared to plain gauze (RR 0.23, 95% CI 0.12 to 0.44) (infection rate of 1% in the PHMB group and 4.5% in the control group) but this study was at high risk of bias as the unit of analysis was observations rather than patients.

    There were no other statistically significant differences between groups in any of the other trials.

Like the first edition, Clarke and Richardson (2008) demonstrate the contemporary ‘Russian’ method (Table 26.4). Variations continue to be adopted by UK practitioners, for example figure of eight bandaging – recurring steps include weekly cleansing, use of pressure at pin sites, no showering of limb in-between showering and cleansing solution. This information should be used in conjunction with local guidelines for wound care, infection control and following discussion and agreement with other relevant members of the healthcare team and reviewed on an on-going basis.

Table 26.4 ‘Russian pin site cleansing’ (Clarke & Richardson 2007).

Points Action Rationale

Prepare patient: seek verbal consent, check patient’s position, and record pain score.

Collect the required equipment:

Dressing pack

Sterile scissors

Sterile gloves


Non-sterile gloves

Forceps (optional)

Hydrex – pink chlorhexedine gluconate 0.5% w/v 70% v/v

‘Non-woven’ gauze squares

Potential pain during pin site dressings.

Offer analgesia if appropriate.

Day 2 post-surgery (approx.), reduce and renew dressings.

Thereafter dressings will be changed at seven-day intervals (a shower can be taken prior to pin site care).

No fibres to be left at pin site.

2. Wash and dry hands, put on plastic apron. Prevent cross infection.
3. Pull back black rubber bungs (see below). To provide access to existing dressings.
4. Apply non-sterile gloves, remove existing bandages, dressings and discard in a clinical waste bag. To expose pin sites.
5. Inspect all pin sites. Observe for signs of infection, etc.
6. Wash hands. Prevent cross infection.
7. Open all sterile dressings and equipment to be used. In preparation for aseptic technique.
8. Apply sterile gloves. To prevent cross infection.
9. Prepare sterile gauze squares by making slit in the gauze (keyhole dressing; see below). To allow gauze to fit over wire at the pin site.
10. Using a separate piece of gauze (gloved finger or forceps), clean each individual pin site with Hydrex- 0.5% w/v 70% v/v alcohol solution using a sweeping action. In an attempt to prevent infection at pin site.
Rubber bung
11. Do not remove crusts or scabs. In an attempt to prevent infection at pin site.
Keep metal work socially clean.
12. Moisten all required gauze squares in Hydrex- 0.5% w/v 70% v/v alcohol solution and remove excess liquid from each gauze square. In an attempt to prevent infection at pin site and reduce skin irritation.
13. Apply the moistened keyhole gauze square dressing to each pin site. Keyhole dressings of gauze, 2–3 layers thick moistened with Hydrex solution – alcoholic chlorohexidine.
Keyhole dressing With excess liquid removed to prevent infection and skin irritation.
14. Position the rubber bung onto each pre-soaked square gauze at each pin site (as demonstrated). To secure gauze stays in position at pin site.
15. Bandaging each pin site (optional) or alternative. Bandaging in figure of eight to secure dressings and ensure that the bungs do not lift.
16. Place solutions in a secure cupboard and discard all dressings, gloves, and apron in clinical waste bag/bin. Health and safety.
To prevent cross infection.
17. Wash hands. To prevent cross infection.
18. Re-assess patient’s pain score. Review analgesia.
19. Teach patient and family a similar regime. Tampering with pin sites excessively can lead to infection.
Keep regime simple and provide instruction. Expect poor or non-compliance.
20. Educate patient/family and community staff to look for signs of pin infection. To identify problems early.
In some cases, arrangements can be made to have the dressings completed by the Ilizarov nurse specialist.
21. Provide verbal and written information with contact numbers. To reduce anxiety, increase compliance, and provide support.
Provide opportunities to contact other patients and support groups.
22. Provide psychosocial support. Pins/wires amount to a major insult to self-image.

Adapted from Davies et al. (2005) and Lee Smith et al. (2001).

Mar 23, 2024 | Posted by in Uncategorized | Comments Off on Ilizarov Frame

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